Purpose

To provide information to the NSW Minister for Health on contracting privately

practicing midwives into the public health sector. This information is related to
the imminent commencement of the National Registration and Accreditation Scheme
for Health Professionals. This scheme will commence on July 1st 2010 and
midwives, in order to appear on the register, will be required to hold
professional indemnity insurance.

Summary:

Midwives currently providing home birth care are able to register as a midwife.
This provides a quality assurance mechanism with the registered midwife being
accountable to professional standards of competence, ethics and conduct.

Exclusion of home birth services from regulation will not improve aspects of
quality and safety. Home birth will fall outside of regulatory mechanisms meaning
that:

* outcomes will be unreported and invisible,

* there will be no professional requirements of those providing the services
(as they will not be registered midwives) and
* there will be no compunction to have appropriate collaborative processes,
back-up and transfer mechanisms.

Australian College of Midwives NSW Branch (ACM NSW) anticipates that some midwives
will choose to continue to practice either underground or as unregistered
caregivers. They will not be able to attend education for updating practice as
they will fear being reported. They will also be less willing to transfer women in
to hospital because of fear of being prosecuted. Such midwives will miss out on
vital professional development.

Recommendations

It is the view of the ACM NSW that the proposed arrangements whereby privately
practicing midwives are unable to obtain professional indemnity insurance, and
therefore are unable to register, are unacceptable and we propose that a
commitment is made to remedy this situation to ensure all women seeking pregnancy
care regardless of place of birth are able to access a registered midwife.

The ACM NSW proposes the following potential recommendations:

1) That a period of exemption be applied to this registration requirement in order
for a sustainable solution to be found whereby midwives in private practice are
able to access professional indemnity insurance to cover the care of women who
choose to birth at home.

2) That during the period of exemption a commitment is made by the government to

work with the regulatory authorities, jurisdiction and professional colleges to
seek solutions considering the following strategies:

* Strategies enabling the extension of existing vicarious liability coverage

afforded to employed health practitioners to cover midwives providing care to
women choosing homebirth, such as the development of contractual arrangements,
protocols and standards with health services for visiting midwives.
* The NSW State Government enter into “fee for service” contracts with
midwives, including determining what arrangements with NSW Treasury are necessary
in relation to the extension of current indemnity to cover such midwives. From NSW
perspective, this will also address some of the recommendations identified by the
Garling Report which recommended public health services enter into contracts with
private midwives to improve access and public safety for women
* That Area Health Services make a commitment to offer public homebirth
services for women who request it.
* That Area Health Services develop protocols which provide options of care
for women who refuse to birth in hospital where plans are put in place to protect
the safety of both the women and midwives and other health professionals.

(See page 8 for further background)

Introduction

The Australian College of Midwives, NSW (ACM NSW) Branch is a non-government, not
for profit, volunteer-based organisation. ACM NSW provides professional support to
midwives as well as a range of information services to women and birthing
families. The ACM NSW is a branch of the Australian College of Midwives (ACM). The
ACM NSW has over 1000 members who are also part of a national membership of nearly
4000 midwives.

The ACM NSW has a number of concerns relating to the requirement that registration
and renewal of registration are to be subject to conditions specified in Clauses
in Bill B. The ACM NSW is concerned that the implementation of the proposed
clauses in this Bill will create unintended consequences for the public safety of
women accessing private midwifery care. ACM NSW recognises that the majority of
midwives working in the public and private health systems will meet the conditions
of registration relating to professional indemnity insurance arrangements by
virtue of their employment. However, a number of midwives working in private
practice may be unable to meet this requirement due to an inability to access
professional indemnity insurance in Australia rendering them ineligible for
registration.

The NSW Minister for Health and NSW Department of Health have been very supportive
in providing women in this State with a variety of models of care including the
development of publicly funded homebirth models. These home birth models are
available now in two Area Health Services (SESIAHS and HNEHEALH). The SESIAHS
provides two publicly funded home birth models with geographic restrictions around
St George Hospital and Wollongong Hospital and HNEHEALTH provides their service in
several parts of the Area Health Service (AHS). All other home birth services in
NSW are provided by privately practicing midwives.

A meeting between the ACM NSW and the NSW Health Minister, the Hon John Della
Bosca was held on the 28th July 2009 with the following representatives of ACM NSW
Associate Professor Hannah Dahlen (ACM Secretary), Ms Joanne Gray (ACM President)
and Ms Suellen Allen (ACM Vice President). The Minister asked the ACM NSW to
prepare a brief with possible NSW State based responses to the imminent problems
of access for women to midwives able to provide home birth services come July 1st
2010.

The ACMNSW commends the NSW Minister for Health’s concern about this issue and
welcomes the opportunity to discuss options to resolve this impending crisis.

Background

In Australia, midwives practice in accord with the international definition of the

midwife (Appendix 1) and work in consultation with women and their families during
pregnancy, birth and subsequent care for the woman and her baby. As providers of
primary health care, midwives offer services that are relevant, accessible, safe
and affordable to the community needs.

Public access to homebirth

The ACM NSW has a number of concerns relating to the requirement that registration
and renewal of registration is to be subject to conditions specified in Bill B.

Access to professional Indemnity insurance for midwives working in private

practice

Clause 101 (1) proposes that if a National Board decides to register a person in
the health profession for which the board is established, the registration is
subject to the following conditions, including:
(a ii) that the registered health practitioner must not practice the health
profession unless professional indemnity insurance arrangements are in force in
relation to the practitioners practice of the profession.

ACM NSW recognises that the majority of midwives working in the public and private
health systems will meet the conditions of registration relating to professional
indemnity insurance arrangements by virtue of their employment. However, a number
of midwives working in private practice may be unable to meet this requirement due
to an inability to access professional indemnity insurance in Australia rendering
them ineligible for registration.

Midwives in Australia have been unable to obtain professional indemnity insurance

for private practice since July 2001. The loss of indemnity did not follow any
significant payout for damages against a midwife. Rather it followed global
uncertainty in the insurance market and increased sensitivity to risk, following
the HIH collapse, and 9/11 in the USA. The relatively small pool of midwives in
private practice in Australia meant insurers judged that there was an insufficient
premium pool to continue to underwrite insurance in this area.

The recent Federal Government budget initiatives to introduce an indemnity scheme

for Medicare eligible midwives in private practice will enable some midwives to
meet the proposed registration requirements. However this scheme will not include
indemnity arrangements for midwives in private practice providing care to women
who choose to birth at home. This is currently the majority of privately
practicing midwives in Australia (around 200). As such, these midwives who were in
the past able to be registered will no longer be eligible for registration due to
their inability to gain the required level of professional indemnity insurance.

It is the view of the ACM NSW that the proposed legislation is creating a gap in
registration eligibility for certain midwives which currently does not exist. In
addition, the ACM NSW is gravely concerned about the unintended consequences for
public safety created for women who will still continue to choose to birth at home
but are no longer able to access the services of a registered midwife. This is
likely to create a situation where women will access the services of unregistered,
unregulated birth attendants who will not have the requisite skills, knowledge or
training to provide a safe service. It would seem inappropriate that legislation
designed to protect the safety of the public seeking health care is creating a
situation when certain members of the public are being put in a situation of
increased risk.

ACM NSW is concerned at the continued inability to obtain affordable insurance by

privately practising midwives. We need a public solution to this problem as we are
hearing more and more stories about women choosing to give birth on their own and
there is now Free Birthing Websites advocating that women who can’t access
midwives can ‘do it themselves.’
The NSW Government has a Policy Directive on publicly-funded homebirth (PD
2006_045). This was released in 2007. Despite this to date, only two AHS in NSW
offer publicly-funded homebirth and these services are often restricted to certain
geographic locations. This means very few women across the state have access to a
safe, cost effective model of home birth care. The rest of the home birth services
are provided by private midwives across the state, many who drive great distances
to meet the needs of women.

Choice of homebirth in Australia

Some Australian women choose to give birth at home. Whilst the exact numbers are
not known due to limitations in data collection, it is around 0.3% of all births.
Internationally, homebirth models that are well accepted and are an integrated
component of maternity services are more popular. In Australia, there are small
pockets where home birth is more easily accessed and a greater proportion of women
make this choice.

Most home births occur with a privately practicing midwife. There are a small
number of publicly funded models across Australia. These are generally in limited
geographic areas and usually located in metropolitan areas (with a few births
occurring in state based models outside metropolitan regions in specific programs
such as that of Hunter New England Health). They also often cater for a defined
group of women – not always confined to those of low risk (e.g. young women or
Aboriginal and Torres Strait Islander women).

Women choosing homebirth often do so out of a desire to maintain control of their

birth experience (Cohen and Dorsey 1998). This control includes the choice of
practitioner to attend their birth. For most women, this choice is only available
in the private sector.

The evidence about the safety of home birth

Homebirth is safe for low risk women in well integrated models of maternity care
(Bastian et al 1998; de Jonge 2009; Symons et al 2009; Ackermann-Liebrich et al.
1996; Northern Region Perinatal Mortality Survey Coordinating Group 1996; Wiegers
et al. 1996; Gulbransen et al. 1997; Murphy & Fullerton 1998; Young et al. 2000;
Janssen et al. 2002; Johnson & Daviss 2005). The research above has also examined
both employed and self-employed midwives. Appendix 2 provides a review of the
literature with a synopsis of several pieces of key research detailing the
evidence of the safety of planned homebirth for low risk women in the care of a
midwife.
There does not appear to be a consensus on the specific criteria to be used for
booking women to birth at home or in hospital (Campbell 1999) and there is no
specific evidence to support different criteria (Nursing and Midwifery Council
(UK) 2005).

Ensuring the safety of midwifery care

Midwives are working hard, both in NSW and nationally, to ensure that they are
skilled and safe practitioners and accountable to the public.

* Credentialing

Credentialing was introduced by NSW Health as an opportunity for midwives to

demonstrate publicly that they are skilled and safe practitioners who are
sufficiently prepared to offer continuity of care to women. There are currently
around 200 credentialed midwives

* National Competency Standards for the Midwife

The National Competency Standards for the Midwife (Australian Nursing and
Midwifery Council) were developed following extensive research with midwives and
key stakeholders throughout Australia and have been released. This report has now
been approved by each state and territory nursing and midwifery regulatory body,
allowing for a nationally consistent framework by which the practice of midwives
can be measured.

* Midwifery Practice Review

A national program for Midwifery Practice Review commenced through the Australian
College of Midwives in February 2006 and the development of this review process
was funded by the Australian Commission for Safety and Quality in Health Care
(Appendix 3)

* Codes of Practice and Ethics for Midwives

The Australian Nursing and Midwifery Council has developed a Code of Conduct and
Code of Ethics for midwives

Maintaining quality and safety

Midwives currently providing home birth care are registered. This provides a
quality assurance mechanism with the registered midwife being accountable to
professional standards of competence, ethics and conduct.

Exclusion of home birth services from regulation will not improve aspects of
quality and safety. Home birth will fall outside of regulatory mechanisms meaning
that:

* outcomes will be unreported and invisible,

* there will be no professional requirements of those providing the services
(as they will not be registered midwives) and
* there will be no compunction to have appropriate collaborative processes,
back-up and transfer mechanisms.

ACM NSW anticipates that some midwives will choose to continue to practice either
underground or as unregistered caregivers. They will not be able to attend
education for updating practice as they will fear being reported. They will also
be less willing to transfer women in to hospital because of fear of being
prosecuted. Such midwives will miss out on vital professional development.

ACM NSW argues that, rather than driving homebirth underground and increasing
risks to mothers and babies, there is a need to ensure standards of practice for
homebirth services. We recognise that there has been an insufficient process to
ensure the quality and safety of the midwives providing care in addition to
registration. We also recognise that this is the case for all midwives providing
care to women.

National regulation, with requirements for recency of practice and with a

requirement of demonstration of continuing professional development, will provide
an improved quality framework. There is also a preparedness to discuss further
measures specific to homebirth under quality and safety frameworks and under
Medicare eligibility requirements

A recent Coronial report in NSW took the unusual step of directing comment to the
Federal (and NSW state) Health Minister stating that the draft national
registration legislation would have the “effect of driving home birthing
‘underground’ which would be a dangerous outcome”(Reimer 2009). The Coroner
further recommends that the Federal Health Minister not take steps that would make
homebirth unlawful but rather examine the minimum standards of qualification,
credentialing process and compliance with the Australian College of Midwives
consultation and referral guidelines for midwives (Reimer 2009).

Recommendations

It is the view of the ACM NSW that the proposed arrangements are unacceptable and
we propose that a commitment is made to remedy this situation to ensure all women
seeking pregnancy care regardless of place of birth are able to access a
registered midwife.

The ACM NSW proposes the following potential recommendations:

1) That a period of exemption be applied to this registration requirement in order

for a sustainable solution to be found whereby midwives in private practice are
able to access professional indemnity insurance to cover the care of women who
choose to birth at home.

2) That during the period of exemption a commitment is made by the government to

work with the regulatory authorities, jurisdiction and professional colleges to
seek solutions considering the following strategies:

* Strategies enabling the extension of existing vicarious liability coverage

afforded to employed health practitioners to cover midwives providing care to
women choosing homebirth, such as the development of contractual arrangements,
protocols and standards with health services for visiting midwives.
* The NSW State Government enter into “fee for service” contracts with
midwives, including determining what arrangements with NSW Treasury are necessary
in relation to the extension of current indemnity to cover such midwives. From NSW
perspective, this will also address some of the recommendations identified by the
Garling Report which recommended public health services enter into contracts with
private midwives to improve access and public safety for women
* That Area Health Services make a commitment to offer public homebirth
services for women who request it.
* That Area Health Services develop protocols which provide options of care
for women who refuse to birth in hospital where plans are put in place to protect
the safety of both the women and midwives and other health professionals.

Details on Recommendation Two

The Special Commission of Inquiry into Acute Services in NSW Public Hospitals –
commonly referred to as the Garling Inquiry was released in November 2008. ACM NSW
put in a submission to the inquiry and witnessed before Garling. Garling
recommended in his report that, NSW Health should address several matters with
respect to its maternity services with the first being:

1. Within 12 months, NSW Health consider and determine whether area health
services be permitted to enter into “fee for service” contracts with midwives,
including determining what arrangements with NSW Treasury are necessary in
relation to the extension of current indemnity to cover such midwives

We understand that the Northern Territory government and most recently the
Victorian government have entered into such arrangements with midwives. While the
expansion publicly funded homebirth models is to be commended these are limited in
number and restricted by geographic boundaries. There are also very few midwives
with skills in offering home birth services.

By entering into contracts with privately practicing midwives AHS would be able
to:

o Provide most women in NSW with the option of a professionally attended

home birth if they meet agreed criteria
o Utilise the skills of privately practicing midwives in providing home
birth services and build up the skills of other midwives in the AHS through
opportunity for a mentoring program
o Enable the privately practicing midwives to have visiting rights,
ongoing education and peer review which has been lacking since 2001
o Enhance quality and safety by having women book into hospitals during
the pregnancy and having guidelines for consultation and referral

Conclusion

The current situation facing women wanting to birth at home is dire. Women are
faced with the prospect of being unable to access the services of a registered
midwife for birth care at home after 1 July 2010, resulting in 3 possible options

1) birth in hospital,

2) to birth at home with an unregulated care provider who may or may not have the
appropriate skills, knowledge and equipment to ensure safety for the mother and
baby, or

3) to birth at home alone with no registered health professional present.

Many women, particularly those who have experienced trauma in an earlier birth in
a hospital, will resort to the latter two options. ACM fears this will result in
an increase in morbidity and mortality for mothers and babies.

References

Ackermann-Liebrich, U., Voegeli, T., Gunter-Witt, K.,Kunz, I., Zullig, M.,

Schindler, C., Maurer, M. & Zurich Study Team, 1996, ‘Home versus hopsital
deliveries: follow up study of matched pairs for procedure and outcome’, BMJ:
British Medical Journal, vol. 313, pp.1313–1318.

Australian Health Workforce Ministerial Council 2009 Exposure draft (Bill B)

Health Practitioner National Regulation law.
http://www.nhwt.gov.au/documents/National%20Registration%20and%20Accreditation/Exp
osure%20draft%20of%20Health%20Practitioner%20Regulation%20National%20Law%202009%20
(Bill%20B).pdf

Bastian H, Keirse MJNC, Lancaster PAL 1998, ‘Perinatal death associated with
planned home birth in Australia: population based study’, BMJ:British Medical
Journal, vol. 317, pp. 384-388.

Commonwealth of Australia. 2009. Improving Maternity Services in Australia – The

report of the National Maternity Service Review.

de Jonge, A, van der Goes, BY, Ravelli, ACJ, Amelink-Verburg, MP, Mol, BW,
Nijhuis, JG, Bennebroek Gravenhorst, J and Buitendijk, SE 2009, ‘Perinatal
mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home
and hospital births’, British Journal of Obstetrics and Gynaecology, DOI:
10.1111/j.1471-0528.2009.02175.x.

Northern Region Perinatal Mortality Survey Coordinating Group 1996, ‘Collaborative

survey of perinatal loss in planned and unplanned home births’, BMJ: British
Medical Journal, vol. 313, pp. 1306-1309.

Campbell, R., Review and Assessment of Selection Criteria Used when Booking
Pregnant Women at Different Places of birth. British Journal of Obstetrics and
Gynaecology 1999 Vol. 106 pp550-556

Chamberlain M, Barclay K, Kariminia A, Moyer A, Aboriginal Birth Psychosocial or

physiological safety. Birth Issues, 2001. 10:3/4. 81-85.

Confidential Enquiry Into Maternal and Child Health, Why Mothers Die 2002 – 2004
6th. Report London: Royal College of Obstetricians and Gynaecologists Press. 2004.

Gulbransen G, Hilton J, McKay L & Cox A 1997, ‘Home birth in New Zealand 1973-93:
incidence and mortality’. New Zealand Medical Journal, vol.110, pp.87-89.

Hancock H, 2005. Aboriginal women’s perinatal needs, experiences and maternity

services: A literature review to enable considerations to be made about quality
indicators. Ngaanyatjarra Health Service, NT.

Houd S, Qinuajuak J, Epoo B, 2003. The outcome of perinatal care in Inukjuak,

Nunavik, Canada 1998-2002. Circumpolar Health, Nuuk. 239-241.

Janssen PA, Lee SK, Ryan EM, Etches DJ, Farquharson DF, Peacock D & Klein MC 2002,
‘

Outcomes of planned home births versus planned hospital births after regulation of
midwifery in British Columbia’, Canadian Medical Association Journal, vol. 166,
pp. 315-23.

Johnson KC & Daviss BA 2005, ‘Outcomes of planned home births with certified
professional midwives: large prospective study in North America’, BMJ: British
Medical Journal, vol. 330, 18 June, pp. 1416-1422.

Joyce H 2009 Doctor in charge. Life Matters. ABC network.

http://www.abc.net.au/rn/lifematters/stories/2009/2614150.htm

Kildea S. 1999. ‘And the women said…Report on Birthing Services for Aboriginal
Women from Remote Tope End Communities’ Territory Health Services. Northern
Territory Senate Community Affairs Reference Committee.

Kildea S, 2001. Birthing in the Bush – Maternity Services in Remote Areas of

Australia. CRANA Conference “From Generalist to Specialist” 28-31//8/01.

Kildea S, Birthing Business in the Bush: It’s Time to Listen. 2005. Unpublished
thesis, Centre for Family Health and Midwifery, University of Technology Sydney.

Magill-Guerdin J 2005 Report of issues arising from a document review to support

recommendations for guidance for home births http://www.nmc-
uk.org/aDisplayDocument.aspx?DocumentID=1981 accessed July 13 2009.

Murphy PA & Fullerton J 1998, ‘Outcomes of intended home births in nurse-midwifery

practice: a prospective descriptive study’, Obstetrics and Gynecology, vol. 92,
pp.461-470.

New Zealand Ministry of Health 2001, Report on Maternity 1999, viewed 24 April
2007,

http://www.moh.govt.nz/moh.nsf/ea6005dc347e7bd44c.

Newman L Newman L. 2008. Why planned attended homebirth should be more widely
supportedin Australia. Australian and New Zealand Journal of Obstetrics and
Gynaecology 2008; 48: 450–453

Northern Region Perinatal Mortality Survey Coordinating Group 1996, ‘Collaborative

survey of perinatal loss in planned and unplanned home births’, BMJ: British
Medical Journal, vol. 313, pp.

1306-1309.

Olsen O & Jewell MD 1998, ‘Home versus a hospital birth’, Cochrane Database of
Systematic Reviews, Issue 3,viewed 24 April 2007,

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000352/frame.ht
ml

Parratt J & Johnston J 2002, ‘Planned homebirths in Victoria, 1995-1998’,

Australian Journal of Midwifery, vol. 15, pp.16-25

Queensland Health 1996. Aboriginal Birthing on Homelands Report. Women’s Health

Unit, Queensland Health.

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Midwives 2007 Position statement No 2. Homebirth
http://www.rcog.org.uk/files/rcog-corp/uploaded-
files/JointStatmentHomeBirths2007.pdf accessed July 10 2009

Reimer N 2009 Report of the Coroner. 26 June 2009.

Symons A, Winter C, Inkster M and Donnan T. 2009. Outcomes for births booked under
an independent midwife and births in NHS maternity units: maternity units: matched
comparison study BMJ 2009;338;b2060; doi:10.1136/bmj.b2060.

Van Wagner V, Epoo B, Nasstapoka J, Harney E, 2007. Reclaiming birth, health, and
community: Midwifery in the Inuit villages of Nunavik, Canada. Journal of
Midwifery Womens Health, 52:4, 384-391.
Wiegers TA, Keirse MJNC, van der Zee J & Berghs GAH 1996, ‘Outcome of planned home
and planned hospital births in low risk pregnancies: prospective study in
midwifery practices in the Netherlands’, BMJ: British Medical Journal, vol .313,
pp.1309-1313.

World Health Organisation 1999, ‘Care in Normal Birth: A practical guide’, Geneva,
W.H.O.

Young G, Hey E, MacFarlane A, McCandlish R, Campbell R & Chamberlain G 2000,

‘Choosing between home and a hospital delivery’, BMJ: British Medical Journal,
vol.320 pp 798-800

19

Appendix 1. International definition of the midwife (2005)

The international definition of the midwife was first created in 1972. The latest
edition was adapted by the International Confederation of Midwives (ICM)[1] in
July 2005 and supersedes the 1972 and 1990 definition.

A midwife is a person who, having been regularly admitted to a midwifery

educational programme, duly recognised in the country in which it is located, has
successfully completed the prescribed course of studies in midwifery and has
acquired the requisite qualifications to be registered and/or legally licensed to
practise midwifery.

The midwife is recognised as a responsible and accountable professional who works

in partnership with women to give the necessary support, care and advice during
pregnancy, labour and the postpartum period, to conduct births on the midwife’s
own responsibility and to care for the newborn and the infant. This care includes
preventative measures, the promotion of normal birth, the detection of
complications in mother and child, the accessing of medical care or other
appropriate assistance and the carrying out of emergency measures.

The midwife has an important task in health counselling and education, not only
for the women, but also within the family and the community. This work should
involve antenatal education and preparation for parenthood and may extend to
women’s health, sexual or reproductive health and child care. A midwife may
practice in any setting including the home, community, hospital, clinics or health
units.
Appendix 2. Safety of Homebirth – Annotated Biblography

de Jonge, A, van der Goes, BY, Ravelli, ACJ, Amelink-Verburg, MP, Mol, BW,
Nijhuis, JG, Bennebroek Gravenhorst, J and Buitendijk, SE 2009, ‘Perinatal
mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home
and hospital births’, British Journal of Obstetrics and Gynaecology, DOI:
10.1111/j.1471-0528.2009.02175.x.

Study subject: 529,688 low risk women. All low risk women giving birth in the
Netherlands between January 2000 and December 2006.

This study shows that planning a home birth does not increase the risks of
perinatal mortality and severe perinatal morbidity among low-risk women, provided
the maternity care system facilitates this choice through the availability of well
trained midwives and through a good transportation and referral system.

Symons A, Winter C, Inkster M and Donnan T. 2009. Outcomes for births booked under
an independent midwife and births in NHS maternity units: maternity units: matched
comparison study BMJ 2009;338;b2060; doi:10.1136/bmj.b2060.

Study included 8676 women – 1462 receiving care from an independent midwife and
7214 receiving care from the NHS (Scotland). NB the place of birth is not a focus
of this study.

Clinical outcomes across a range of variables were significantly better for women
accessing an independent midwife, there were significantly higher perinatal
mortality rates for high risk cases in this group. When high risk cases were
removed from both groups – perinatal mortality for low risk women was the same in
both groups.

Johnson, K & Daviss, BA 2005, ‘Outcomes of planned home births with certified
professional midwives: large prospective study in North America’, British Medical
Journal, DOI: 10.1136/bmj.330.7505.1416, viewed 8 July 2009, <www.bmj.com>.

Study all 5419 women who planned to give birth at home with a midwife in the US in
the year 2000.

The study concluded that planned home birth for low risk women in North America
using certified professional midwives was associated with lower rates of medical
intervention but similar intrapartum and neonatal mortality to that of low risk
hospital births in the United States.

Bastian H, Keirse MJNC, Lancaster PA ‘Perinatal death associated with planned home
birth in Australia: population based study’ in BMJ 1998:317-384-388

7002 homebirth (all Australian homebirths between 1985 and 1990) were studied.

Authors found that home birth for low risk women compares favourably with hospital
birth, high risk homebirth is inadvisable and experimental.

Northern Region Perinatal Mortality Survey Coordinating Group. Collaborative

survey of perinatal loss in planned and unplanned home births. BMJ 1996;313: 1306-
9.

Review of 558,981 births. Perinatal hazard associated with planned homebirth was
very low. The perinatal mortality of women who had no plan for professional care
in labour was high.

Olsen O. Meta-analysis of the safety of home birth. Birth 24,1 (1997) 4-13.

Meta-analysis of sic controlled observational studies of 24,092 low risk women.

Conclusion home birth is an acceptable alternative to hospital confinement for

selected pregnant women and leads to reduced medical interventions.

Janssen PA, Lee SK, Ryan EM, Etches DJ, Farquharson DF, Peacock D & Klein MC 2002,
‘Outcomes of planned home births versus planned hospital births after regulation
of midwifery in British Columbia’, Canadian Medical Association Journal, vol. 166,
pp. 315-23.

Study of 862 planned home births compared with 571 hospital attended midwife
births and 743 hospital attended physician births.
Conclusion no increased maternal or neonatal risk associated with planned
homebirth under the care of a regulated midwife.

Appendix 3 – The Midwifery Practice Review (MPR) program

MPR was developed by the Australian College of Midwives (ACM) in 2007 with funding
from the Australian Commission on Safety and Quality in Healthcare (ACSQHC).

The program, operating since September 2007, obliges each midwife to provide a
range of information about their practice ahead of their review including a CV,
philosophy of practice, MidPLUS record, practice statistics, consumer, manager and
self reflection of practice. The midwife then must participate in a face to face
review meeting with 2 accredited MPR reviewers. The midwife must demonstrate that
she/he:

• Practices according to the full role and scope of practice of a midwife as

identified by the WHO.

• Practices consistently with the provisions of the Australian Nursing and

Midwifery Council (ANMC) National Competencies for the Midwife, Code of Ethics for
Midwives, and Code of Professional Conduct for Midwives

• Identifies and provides a critical analysis of statistical data regarding

her/his individual practice and may also include data for the institution in which
she/he works.

• Reflects upon her/his individual practice and incorporates evidence-based

research, continuous quality improvement and best practice principles into
practice.

• Has a professional development plan and evidence of participating in relevant

continuing professional development activities

• Engages in feedback from women about the care they have received

Appendix 4 – Australian College of Midwives Position Statement

Draft Position Statement on Planned Home Births with a Midwife

The Australian College of Midwives believes that the opportunity to give birth at
home should be offered to women who have uncomplicated pregnancies and labours.
The College supports a woman’s right to self-determination and control over her
body and her pregnancy, including the right to give birth in the place of her
choice. Some women prefer to give birth in the familiar, comfortable surroundings
of their own home because they feel this is the safest place for them and their
baby. Birth for women is a rite of passage and a family event; it is an intense
physical and psychological journey that can leave women vulnerable to physical and
emotional trauma but also potentially open to enormous personal self-growth. The
physical and psychological care of childbearing women are therefore inextricably
linked.
Evidence supports both the safety of homebirth for women with uncomplicated
pregnancies (1-4) and the requirement for timely transfer from home with access to
the full health care team in a hospital facility for women who experience
complications during their pregnancy or in labour, to prevent increased morbidity
and mortality for mother and baby (5; 6).

The rate of home births in Australia remains low at approximately 0.30% (7), in
large part due to the unavailability of insurance and the lack of public funding
for private midwives. It has been estimated that where safe homebirth is supported
and offered to women with low risk pregnancies, the rate of home births may well
be around 8–10% (8).

Just as the Australian College of Midwives supports women’s right to choose high
quality midwifery services in both the public and private systems, so too the
College supports a midwife’s right to choose to be self employed or employed.

Aim of this position statement

To provide women, midwives and other health practitioners with a clear

understanding of where the peak professional body for Australian midwives stands
in relation to women giving birth at home.

Guiding requirements for women

That a woman planning to give birth at home has:

* an uncomplicated singleton pregnancy at term

* access, including a booking, into a nearby hospital with secondary or
tertiary facilities
* been informed as to the specific reasons for possible transfer out of the
home environment and requirements to ensure timely transfer
* agreed to listen to her midwife’s advice when transfer may be needed
* the right to refuse all or any aspects of care
* the right to a home visit by her primary midwife and the midwife’s associate
to discuss available evidence of risk and document the woman’s informed refusal

Guiding requirements for midwives

That a midwife planning to provide midwifery care to a woman at home

* is a Registered Midwife.
* is a Medicare Eligible Midwife (see Eligibility criteria)
* is experienced in attending homebirths or is attending the labour and birth
with a midwife experienced in attending homebirths.
* informs women about the range of antenatal, labour and birth and postnatal
care options and their advantages and disadvantages
* utilises the ACM National Midwifery Guidelines for Consultation and Referral
* demonstrates effective communication and collaboration processes with other
health professionals
 * communicates and documents a plan of care for home birth that is centred
around the woman’s wishes
* has planned referral pathways for pregnancy and during the woman’s labour
and birth,
* has visiting access to local hospital/s
* plans for two midwives to attend the birth where possible (a second midwife
will arrive at the discretion of the primary midwife and/or the woman’s wishes)
* retains the right to organise alternative provision of care for a woman
antenatally if there are concerns about the safety of the woman and her baby
* has a responsibility to remain with a woman in labour if the woman declines
the midwife’s advice to transfer to hospital, to record the events and to contact
a colleague for support and ongoing advice
* has a right to expect that on transfer to a secondary or tertiary health
facility, she as the midwife, will be treated with respect and that the woman’s
health care needs and those of her baby will be the central focus of the health
care

Guiding requirements for maternity services

That maternity providers

* provide professional information for every woman on a range of birth

environment options
* discuss the potential advantages or disadvantages of home birth and hospital
birth with every woman
* inform women about the full range of antenatal care and facilitate the
choice for their particular place of birth
* facilitate visiting access for eligible midwives
* support and include midwives in peer review and ongoing professional
development (MidPlus and MPR).
* facilitate a safe and woman-centred process for women who request vaginal
breech birth, vaginal birth after caesarean, vaginal twin birth etc in hospital or
refer on to another practitioner/centre
* plan referral pathways with women choosing homebirth that are agreed during
her pregnancy and continue during her labour, birth and postpartum period
* agree to work with planned referral pathways to ensure effective
communication and appropriate mutual collaboration between the woman’s midwife and
other maternity service providers
* agree to respect the primary relationship developed between the woman and
midwife over many months of the woman’s pregnancy
* include the woman’s midwife during the process of consultation or referral
as an integral part of the health professional team.

References

1. Johnson K, C., Daviss B. Outcomes of planned home births with certified

professional midwives: large prospective study in North America. British Medical
Journal 2005;330:1416-1423.

2. de Jonge A, van der Goes B, Ravelli A et al. Perinatal mortality and morbidity
in a nationwide cohort of 529,688 low risk planned home and hospital births.
British Journal of Obstetrics & Gynaecology 2009;DOI: 10.1111/j.1471-
0528.2009.02175.x.
3. Wiegers T, Keirse MJNC, van der Zee J. Outcome of planned home and hospital
births in low risk pregnancies: prospective study in midwifery practice in the
Netherlands. BMJ 1996;313(7068):1309-1313.

4. Olsen O. Meta-analysis of the safety of homebirth. Birth 1997;24(1):4-13.

5. Bastian H, Keirse MJ, Lancaster P. Perinatal death associated with planned home
birth in Australia: population based study. BMJ 1998;317(7155):384-388.

6. Symon A, Winter C, Inkster M, Donnan P. Outcomes for births booked under an

independent midwife and births in NHS maternity units: matched comparison study.
British Medical Journal 2009;BMJ 2009;338:b2060.

7. Laws P, Hilder L. Australian mothers and babies 2006. In. Sydney: AIHW National
Perinatal Statistics Unit, 2008.

8. RCOG, RCM. Royal College of Obstetricians and Gynaecologists/Royal College of

Midwives Joint statement: Home births In:
http://www.rcmnormalbirth.net/webfiles/Statement/Home%20Births_Joint%20Statement.p
df, ed. Vol. No.2, April 2007, 2007.

[1] International Confederation of Midwives, Definition of the Midwife, 17th July

2005. http://www.internationalmidwives.org